=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003681081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL PEARSON/SOUTH BAY THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2023
-----------------------------------------------------
Last Update Date | 01/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2413 BURRITT AVE
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90278-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-936-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 ROSECRANS AVE STE 500
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90266-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-936-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL ALAN PEARSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 310-936-8840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------